Innovation at scale: hygiene behaviour change through routine immunization

Each year, World Water Week takes place in Stockholm, Sweden. World leaders from various sectors come together to exchange ideas about the most pressing water challenges of today. In advance of this year’s global gathering, Take on Typhoid spoke with Dr Om Prasad Gautam to learn about WaterAid’s approach to tackling some of today’s biggest health issues, and to learn how immunization programmes offer key and sustainable entry points to integrate hygiene behaviour change.

Q: Om, can you tell us about WaterAid’s work in Nepal?

A: WaterAid has been working in Nepal since 1987 focusing on water, sanitation, and hygiene (WASH). Despite significant progress in reducing child mortality during the past few decades, enteric and diarrheal diseases remain a leading cause of child mortality. In April 2012, WaterAid began exploring opportunities to incorporate hygiene promotion into routine immunization programs. In 2014, we partnered with the Nepal Ministry of Health, Child Health Division to launch a novel pilot project at scale to do just that.

Q: What did you hope to accomplish with this pilot project?

A: The project identified immunization as an entry point for hygiene promotion. Caregivers bring their children in for routine vaccinations at least five times during a child’s first years, so it was a natural opportunity to expose mothers to an attractive, engaging, and motivational hygiene promotion intervention to change key behaviours and form positive hygiene habits to help prevent enteric and diarrheal diseases. The pilot project also explored whether such an approach could strengthen the vaccination programme, build the capacity of female community health volunteers and health workers, and offer a sustained mechanism for integration.

Q: So the project piloted the idea that immunization and hygiene promotion can be integrated for substantial behaviour change, strengthened programming, and ultimately, health impact?

A: Yes. Caregivers of children under one spent 45 minutes with health workers or female community health volunteers before vaccinating their children. They were exposed to creatively-designed hygiene intervention activities with a central motivation to be an ‘ideal family’ by fully immunizing children and practicing hygienic behaviours. To motivate and create a social desire to do key behaviours, caregivers were exposed five times to engaging hygiene activities such as games, stories, competitions, songs, public commitments, and rewards. In each exposure, five key hygiene behaviors were reinforced: exclusive breastfeeding, food hygiene, handwashing with soap, household water and milk treatment, and hygienic use of the toilet including child fecal disposal.

We were innovative and creative to make each hygiene session fun for the caregivers and children. We had visual props and cues such as branded mirrors with illustrations of key behaviours as a reminder; the caregivers placed them in their house to reinforce behaviours when they looked in the mirror. We also had baby bibs that said “Did you wash your hands before feeding me?” and a fan with key behaviours and the vaccination schedule.

Q: Can you say a little about the focus on preventing enteric and diarrheal diseases?

A: The World Health Organization/UNICEF model for reducing diarrhea and pneumonia follows the “protect, prevent, treat” (PPT) holistic approach to ensure children stay healthy and then receive appropriate treatment when they do fall ill. We chose to focus on prevention (and a small bit on protection), bringing together vaccines alongside handwashing, water treatment, safe sanitation, food preparation, and breastfeeding (the protection part). As a global community, we are facing increased threats of drug resistant pathogens. Preventing disease transmission with vaccines plus WASH is a cost effective way to keep children from needing potentially expensive courses of antibiotics. Many countries are in the process of introducing enteric vaccines, including Rotavirus, cholera, and typhoid, and it is important that hygiene promotion is positioned alongside these vaccines to have maximum impact on children’s health.

Q: So what’s next for the program in Nepal?

A: Well, our results from the pilot were quite strong. We used a third party evaluator to help us measure project outcomes; data show that at baseline, only 2% of all caregivers were doing all five of the good hygiene behaviors. After only 15 months of the project, 53% of caregivers had adopted all five behaviors successfully. The intervention also strengthened the routine immunization coverage, reduced drop-out rate, and built the confidence among health workers or female community health volunteers to implement these novel approaches. Nepal’s immunization coverage is quite strong, so we are hopeful that we can replicate these results more broadly. The government of Nepal is retaining this programme in the original four districts and is now working to scale up this approach nationwide—that’s 77 districts with a target population of 700,000 annually. The hygiene intervention will be integrated into the routine immunization programme nationwide later this year when Rotavirus vaccine is introduced. We are also exploring opportunities to replicate a similar model in other countries.

Q: Wow, national scale up is great. Can you tell us why you’re passionate about the integrated WASH plus immunization approach?

A: Firstly, all caregivers want thriving and healthy children, and we know that without integrated approaches, children are less able to thrive. Secondly, we have seen that a child coming for their vaccines offers a routine and sustained mechanism to promote WASH behaviours and strengthen the immunization programme, but it has always been a missed opportunity for integration. Thirdly, the health sector is introducing new enteric vaccines into routine immunization (such as Rota, cholera, typhoid), and due to the nature of these diseases and the potential for reduced vaccine efficacy in environments where WASH behaviours are lacking, it is important that we motivate the practice of hygiene behaviours using comprehensive approaches for the benefit of the children. Such approaches will also help to retain the trust among people about vaccines, as well as maximize the health benefits. Fourthly, national governments have the right mechanism to implement at scale; and with technical support we can implement the WASH behaviour change programme to maximize both health and behavioral outcomes. Lastly, to attain universal health coverage and meet the 2030 goal for everyone everywhere to have access to WASH, it is important that both WASH and the health sector find a clear integration opportunity at scale.

If you are in Stockholm for World Water Week, you can see Dr Om Prasad Gautam present his work on August 26, from 2:00-3:30pm in the ‘Hygiene behaviour change; what works and what doesn’t’ session.

Photo Credit: WaterAid/Om Prasad Gautam